Diver Medical | Participant Questionnaire
Please read this document thoroughly. Any scuba diving activity REQUIRES this form to be filled out. Failure to follow it's instructions may result in any diving activities being delayed. We do NOT allow any student to dive without this form being completed.
Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/ or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.
Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.
Note to women: If you are pregnant, or attempting to become pregnant, do not dive.
If you answered NO to all 10 questions above, further medical evaluation is NOT required and you may continue to the bottom of this page to sign (skipping all additional "box" questions below. Please read and agree to the participant statement at the bottom of the page by signing it.
* If you answered YES to question 3, 5 or 10 above please read and agree to the statement at the bottom of this page by signing it AND taking all pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.
BOX A – I HAVE/HAVE HAD:
BOX B – I AM OVER 45 YEARS OF AGE AND:
BOX C – I HAVE/HAVE HAD:
BOX D – I HAVE/HAVE HAD:
BOX E – I HAVE/HAVE HAD:
BOX F – I HAVE/HAVE HAD:
BOX G – I HAVE HAD:
If you answered YES to any of the questions in questions 1-10 OR boxes A-G, please read and agree to the statement at the bottom by signing it AND YOU MUST take all pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.
Participant Name: ______________________________________ Birthdate: ________________________
The above-named person requests your opinion of his/her medical suitability to participate in recreational scuba diving or freediving training or activity. Please visit uhms.org for medical guidance on medical conditions as they relate to diving. Review the areas relevant to your patient as part of your evaluation.
______________________________________________________Signature of certified medical doctor or other legally certified medical provider
Medical Examiner’s Name (print): _________________________________________
Clinical Degrees/Credentials: ____________________________________________
Phone: _______________________ Email:______________________________
Physician/Clinic Stamp below (optional):
I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Diver Medical | Participant Questionnaire
Agree & Sign